Overview of DC’s Personal Care Aide Services
The District of Columbia’s Medicaid State Plan Personal Care Aide Services Program, or PCA Services, is available to residents who are aged or disabled and require assistance with their daily living activities. Intended to assist these persons in living independently in their homes, program participants receive assistance with bathing, grooming, dressing, toiletry, mobility, meal preparation, and eating.
Program participants can live in their own home or that of a loved one. PCA Services are not available to persons residing in an assisted living residence or adult foster care home.
While many home and community based services (HCBS) Medicaid programs allow program participants to self-direct their own care, specifically allowing them to hire their own caregiver, this is not an option for State Plan Personal Care Aide Services. Instead, program participants must receive assistance from a Personal Care Aide from a DC Medicaid-enrolled home health agency (provider agency).
The District of Columbia’s State Plan Personal Care Aide Services, which may formally be called Personal Care Aide Services Long Term Care Services and Supports (LTCSS), are available through the Regular Medicaid program. PCA Services are an entitlement; meeting the state’s Medicaid eligibility requirements guarantees one will receive assistance. In other words, there is never a waiting list.
While home and community based services (HCBS) can be provided via a Medicaid Waiver or a state’s Regular Medicaid plan, HCBS through Medicaid State Plans are an entitlement. This means meeting the program’s eligibility requirements guarantees an applicant will receive benefits. On the other hand, HCBS via Medicaid Waivers are not an entitlement. Waivers have a limited number of participant enrollment slots, and once they are filled, a waitlist for benefits forms. Furthermore, HCBS Medicaid Waivers require a program participant require the level of care provided in a nursing home, while State Plan HCBS do not always require this level of care.
Benefits of DC’s Personal Care Aide Services
Program participants can receive safety monitoring, prompting, and hands-on assistance with a variety of activities. These may include the following.
– Ambulation
– Bathing
– Continence Care – i.e., changing urinary drainage bags and incontinence protective underwear
– Dressing
– Eating
– Grocery Shopping
– Grooming
– Infection Control
– Medical Appointment Accompaniment
– Medication Assistance –generally those that are self-administered
– Meal Preparation
– Monitoring of Physical Condition / Behavior / Appearance
– Range of Motion Activities
– Telephone Use
– Toileting / Bedpan
– Transferring
– Vital Sign Monitoring (i.e., heart rate, respiration rate, temperature)
Eligibility Requirements for DC’s Personal Care Aide Services
State Plan PCA Services are for District of Columbia residents who are aged or disabled. Additional eligibility criteria follows and is relevant for seniors.
Financial Criteria: Income, Assets & Home Ownership
Income
In 2024, the individual applicant income limit is $1,255 / month. Married applicants, regardless of if one spouse or both are applicants, are limited to $1,703 / month in income. These income limits are equivalent to 100% of the Federal Poverty Level for a household of one and a household of two.
Assets
In 2024, the asset limit is $4,000 for a single applicant. For married couples, it is $6,000, regardless of whether one spouse or both are applicants.
Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.
While there is a 60-month Look-Back Rule in which Medicaid checks past asset transfers of those applying for Nursing Home Medicaid or home and community based services via a Medicaid Waiver, it does not apply to the State Plan Personal Care Aide Services Program.
Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that DC Medicaid will take it. Applicants for the State Plan Personal Care Aide Services Program need not worry. As long as they live in their home, the home is exempt (non-countable). However, if they live in a relative’s home, they must have “Intent to Return” in order for it to remain exempt. For other DC Medicaid programs, such as the EPD Waiver and Nursing Home Medicaid, there are additional requirements for home exemption. More on when Medicaid can and cannot take the home.
Medical Criteria: Functional Need
While many Medicaid long-term care programs require an applicant to have a Nursing Facility Level of Care (NFLOC) need, this is not required for the State Plan Personal Care Aide Services Program. The applicant, however, must require assistance with at least one of the Activities of Daily Living (ADL), such as bathing, dressing, eating, transferring, mobility, and toileting. An in-person functional needs assessment is completed, and based on the results, a functional assessment score is generated. If one’s score is between 4 and 8, the functional need criteria is met. While persons with Alzheimer’s disease or a related dementia might meet the functional need for care, a diagnosis of dementia in and of itself does not mean one will do so.
Qualifying When Over the Limits
Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Medicaid in Washington DC. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.
Persons who have income over the limit, but have high medical bills, can become income-eligible via DC’s Medically Needy Spenddown program. This program permits applicants to spend their “excess” income on medical expenses in order to meet the Medically Needy income limit. The amount that must be paid each month can be thought of as a deductible. Once one’s “deductible” has been met for the month, DC Medicaid will pay for State Plan Personal Care Aide Services. More about the Medically Needy Pathway to eligibility.
When persons have assets over the limits, Irrevocable Funeral Trusts (IFTs) are an option. IFTs are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Persons may also “spend down” countable assets on ones that are exempt (not counted) from Medicaid’s asset limit. The includes making home reparations and modifications, purchasing home furnishings, and even taking a vacation. There are many other Medicaid planning strategies available when the applicant has assets exceeding the limit.
Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid Planners are educated in the planning strategies available in the District of Columbia to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, while Medicaid’s 60-month Look-Back Rule does not apply for State Plan PCA Services, it does apply to Nursing Home Medicaid and the EPD Medicaid Waiver. As more extensive Medicaid-funded care might be required in the future, it is vital that one not violate the Look-Back rule. Medicaid planning strategies should ideally only be implemented with careful planning and well in advance of the need for long-term care. However, there are some workarounds, and Medicaid Planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid Planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid Planner.
How to Apply for DC’s Personal Care Aide Services
Before You Apply
Prior to submitting an application for State Plan PCA Services, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a Medicaid Eligibility Test to determine if one might meet Medicaid’s eligibility criteria.
As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security cards, Medicare cards, life insurance policies, property deeds, pre-need burial contracts, prior bank statements, and proof of income. A common reason applications are delayed is required documentation is missing or not submitted in a timely manner.
Application Process
To be eligible for the State Plan Personal Care Aide Services Program, one must be eligible for Medicaid in the District of Columbia. Persons can apply for Medicaid in person at an ESA Service Center, by completing and submitting an Integrated Application for Public Assistance Benefits (found halfway down the webpage), or by calling the ESA Public Benefits Call Center at 202-727-5355.
To initiate the functional needs assessment, a Prescription Order Form (POF) must be completed by a doctor or APRN (advanced practice registered nurse) who is enrolled as a DC Medicaid Provider. The POF must be submitted to Liberty Healthcare per instructions on the form.
Persons can also call the Department of Aging and Community Living (DACL) at 202-724-5626 or the Department of Health Care Finance Long Term Care Administration at 202-442-5988 to learn more about PCA Services. The State Plan Personal Care Aide Services Program is administered by the Washington DC Department of Health Care Finance (DHCF).
Approval Process & Timing
The District of Columbia Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even further.